Reference this article to find identification criteria for care management.
Care management categories include:
- High Medical Needs
- Emerging Risk
- Potential Home Health / DME Needs
- High Risk Pregnancy
- Severe and Persistent Mental Illness
- Definitions
High Medical Needs
High Medical Needs patients are identified as members that have the frailty flag turned on, have at least one hospital dominant morbidity type, and have at least five chronic conditions. In addition, by specifying a total cost band less than eight (8), only patients with prior costs below the 95th percentile are included, which potentially provides a subset of patients not already enrolled in a case management program.
Emerging Risk
This is a group of patients that are lower cost this year (based on a Total Cost Band < 7), but predicted to be high cost next year (based on a Rank Probability High Total Cost > 0.4).Patients with ESRD (REN06), cancer (MAL), transplant (ADM03) and HIV (INF04) have also been excluded, as typically patients with these conditions will already have been identified for complex case management programs.
Potential Home Health / DME Needs
The frailty flag represents a set of diagnosis codes that describe clinically frail individuals (greater than or equal to 18 years of age) and are highly associated with marked functional limitations. Frailty concepts included are Absence of Fecal Control (AFC), Decubitus Ulcer (DEC), Dementia (DEM), Difficulty in Walking (WLK), Fall (FAL), Loss of Weight (WEI), Major Problems of Urine Retention or Control (URC), Malnutrition and/or Catabolic Illness (MAL), Severe Vision Impairment (VIS), and Social Support (SSN).
The presence of this marker may be an indicator of support needs, such as home care, DME, transportation assistance, etc. Nursing Service is a binary flag (0 = No, 1 = Yes) to indicate that a patient has used services in a nursing home, domiciliary, rest home, assisted living, or custodial care facility during the observation period. By setting Nursing Service = 0 in the following figure, patients who are receiving services in a nursing facility are excluded, as these patients are likely receiving the necessary assistance with their activities of daily living.
Patients with cancer (MEDC MAL), ESRD (EDC REN06), transplant (EDC ADM03) or HIV (EDC INF04) are also excluded, as typically patients with these conditions will already be in a case management program.
Finally, the chronic condition count has been limited to patients with a maximum of five chronic conditions, primarily to show that this may identify a different group of patients than were already identified as high medical need patients.
High Risk Pregnancy
Pregnancy without delivery is an important marker for predicting future resource use and has been used in every version of the ACG Predictive Models. The availability of date and procedure information provides the opportunity to further refine this important marker. If date of service is available, this marker will consider the order of events to capture the latest pregnancy status during the observation period in the event that a pregnancy does not continue to delivery or the patient experiences multiple pregnancies during the year.
Criteria for identification of patients with potential for high risk pregnancies:
- ACG 1762 = Pregnancy (6+ ADGs, no Major ADGs, not delivered)
- ACG 1772 = Pregnancy (6+ ADGs, 1+ Major ADGs, not delivered)
- EDC PSY02 (substance abuse)
- PSY03 (tobacco use)
- PSY06 (family and social problems)
- INF04 (HIV/AIDS)
- CAR15 (hypertension, with major complications)
- Pregnant patients who have not seen an eligible provider for a face-to-face visit during the observation period (Unique Provider Count)
Severe and Persistent Mental Illness
ADGs provide a good foundation for identifying members with severe and persistent mental illness. ADGs classify diagnoses into a limited number of clinically meaningful, but not disease-specific, morbidity groups. Each ADG is homogenous with respect to specific clinical criteria and their demand on healthcare services. ADGs are highly predictive of current and future resource use and take into account the expected duration of the condition, the implied severity of the condition, the level of diagnostic certainty, the etiology of the condition, and whether or not specialty care services are likely to be used.
Two ADG categories, ADG 24 (Psychosocial: Recurrent or Persistent, Stable) and ADG 25 (Psychosocial: Recurrent or Persistent, Unstable) are used to assess the level of mental health disease burden within the population. Using both ADGs together may result in the identification of a large number of candidates for a behavioral health management program, but may not isolate the group of members that would most benefit from program interventions.
A subset of the psychosocial EDCs (e.g., PSY07 - Schizophrenia and affective psychosis, PSY12 - Bipolar disorder, PSY20 - Major depression, etc.), the predictive risk scores and/or the Hospital Dominant Morbidity Types are used to further stratify the population. Frequently individuals have both complex medical and behavioral health conditions, and determining which morbidity is driving the overall healthcare needs may be unclear.
Definitions
Frailty Flag: The Frailty Flag is a dichotomous (on/off) variable that indicates whether an enrollee over the age of 18 has a diagnosis falling within any one of 10 clusters that represent medical problems associated with frailty. Examples of these problems are shown in the following table.
Malnutrition and/or Catabolic Illness (MAL)
- Nutritional Marasmus
- Other severe protein-calorie malnutrition
Dementia (DEM)
- Senile dementia with delusional or depressive features
- Senile dementia with delirium
Severe Vision Impairment (VIS)
- Profound impairment, both eyes
- Moderate or severe impairment, better eye/lesser eye: profound
Decubitus Ulcer (DEC)
- Decubitus Ulcer
Major Problems of Urine Retention or Control (URC)
- Incontinence without sensory awareness
- Continuous leakage
Loss of Weight (WEI)
- Abnormal loss of weight and underweight
- Feeding difficulties and mismanagement
Absence of Fecal Control (AFC)
- Incontinence of feces
Social Support Needs (SSN)
- Lack of Housing
- Inadequate Housing
- Inadequate material resources
Difficulty in Walking (WLK)
- Difficulty in walking
- Abnormality of gait
Fall (FAL)
- Fall on Stairs or Steps
- Fall from Wheelchair
Presence of any one of these diagnoses turns on the FRAILTY indicator (yes/no) variable. Among commercially insured populations, less than one percent of individuals have at least one of these frailty diagnoses, whereas among Medicare beneficiaries the proportion is greater than seven percent.
Hospital Dominant Morbidity: Hospital dominant morbidity types are based on diagnoses that, when present, are associated with a markedly greater probability of hospitalization among affected patients in the next year. All these diagnoses are setting-neutral, i.e., they can be given in any inpatient or outpatient face-to-face encounter with a health professional. The variable is a count of the number of morbidity types (i.e., Adjusted Diagnosis Groups) with at least one hospital dominant diagnosis.
Resource Bands or Cost Bands (Risk Category): ACGs were designed to represent clinically logical categories for persons expected to require similar levels of healthcare resources (i.e., resource groups). However, enrollees with similar overall utilization may be assigned different ACGs because they have different epidemiological patterns of morbidity. For example, a pregnant woman with significant morbidity, an individual with a serious psychological condition, or someone with two chronic medical conditions may all be expected to use approximately the same level of resources even though they each fall into different ACG categories. In many instances it may be useful to collapse the full set of ACGs into fewer categories, particularly where resource use similarity, and not clinical cogency, is a desired objective.
ACGs are collapsed according to concurrent relative resource use in the creation of Resource Utilization Bands (RUBs). The software automatically assigns six RUB classes:
- Non Users
- Healthy Users
- Low
- Moderate
- High
- Very High
Chronic Condition Count: The ACG System includes a chronic condition count as an aggregate marker of case complexity. A chronic condition is an alteration in the structures or functions of the body that is likely to last longer than twelve months and is likely to have a negative impact on health or functional status. The ACG System defines a limited set of Expanded Diagnosis Clusters (EDCs) that represent high impact and chronic conditions likely to last more than 12 months with or without medical treatment.
Compassionate Care Allowances (CAL-SSA): The intent of the Compassionate Care Allowances is to identify persons who have an increased risk of hospitalization. This marker complements other ACG System markers that identify vulnerable groups such as Frailty and Hospital Dominant Morbidity Types.
The Compassionate Care Allowances marker was created by the U.S. Social Security Administration to identify types of impairment that invariably meet disability standards5 and are, thereby, sufficient to allow an individual to become immediately eligible for benefits. The conditions that qualify for Compassionate Allowances include many cancers, amyotrophic lateral sclerosis (ALS), some types of muscular dystrophy and muscular atrophy, early-onset Alzheimer's disease, and a few other illnesses. The presence of an eligible diagnostic code triggers this dichotomous (on/off) marker.
Nursing Service Marker: The nursing service marker identifies the presence of nursing home services through procedure codes. The default for this marker is 0. Flag with a 1 any patients with an instance of a procedure code indicating nursing services.
CPT Codes for Nursing Services
- 94004 - 94005, 99304 - 99337
Dialysis Service Marker: The dialysis service marker identifies the presence of (outpatient) dialysis services using procedure codes for patients who have chronic renal failure. The default for this marker is 0. Flag with a 1, any patients with a diagnosis for chronic renal failure recorded at any time during the observation period that also have at least one ICD, CPT, or HCPCS procedure code indicating dialysis.
Diagnosis Codes for Chronic Renal Failure
- ICD-9-CM: 585, 586, V451, V56, V560, V561, V562, V568, 587, 7925, V5631, V5632, 45821, 5851, 5852, 5853, 5854, 5855, 5856, 5859
- ICD-10: N18.x, N19, Z49.x, Z99.2
ICD Procedure Codes for Dialysis
- ICD-9-CM: 38.95, 39.27, 39.42, 39.95, 54.98
- ICD-10-PCS: 3E1M39Z, 5A1D00Z, 5A1D60Z
CPT Codes for Dialysis
- 90918, 90919, 90920, 90921, 90922, 90923, 90924, 90925, 90935, 90937, 90939, 90940, 90945, 90947, 90989, 90993, 90997, 90999, 93990, 99512
HCPCS Codes for Dialysis
- G0308, G0309, G0310, G0311, G0312, G0313, G0314, G0315, G0316, G0317, G0318, G0319, G0320, G0321, G0322, G0323, G0324, G0325, G0326, G0327, G0365